CLOSED DOOR COACHING

PART 1
Situation: Nurse Kathy is caring for a postpartum
patient. Routine postpartum care is rendered to the
patient.
1. Which assessment finding would lead the nurse to
suspect a postpartum hemorrhage? Blood loss ____.
a. Less than 300ml/24 hours
b. More than 400ml/ 24 hours
c. Less than 200ml/ 24 hours
d. More than 500ml/ 24 hours
2. Which of the following is caused by the markedly
distended uterus and intermittent uterine
contractions within 2 to 3 days after birth?

a. Retained placenta
b. Uterine atony
c. Afterpains
d. Boggy uterus
3. The nurse prepares a care plan for the patient. Based on Ramona
Mercer’s become a mother (BAM) theory, which of the following
statements fosters the process of becoming a mother?

a. The woman becomes comfortable with her identity as a married

individual.
b. It encompasses the dynamic transformation and evolution of
women’s persona.
c. A woman learns mothering behavior prior as early as a teenager.
d. It accurately reflects the transitional process from being single to
a married relationship.
4. The mother asks why she has a gush of blood coming out
from the vagina that occurs when she first arises from bed.
The nurse’s CORRECT response should be ____.
a. “Blood pools at the top of the vagina and forms clots
that are passed upon rising or sitting on the toilet”
b. “Positioning causes blood to flow out when she stands.”
c. “Because of the normal pooling of blood in the vagina
when the woman lies down to rest or sleep.”
d. “Normal physiologic occurence that results as the body
attempts to eliminate excess fluids.”
5. Some postpartum mothers will experience difficulty
voiding because of the edema and trauma of the
perineum. Which priority nursing measures stimulate
the sensation of voiding?
a. Encouraging her to void.
b. Running water in the sink or shower.
c. Helping the mother into the shower.
d. Providing cold tea or fluids of choice.
Situation: A postpartum mother newly delivered her baby
per vagina. She keeps on asking the nurse when the basic
physiologic change occur as her body returns to a
prepregnant state.
6. The nurse explain to the mother that the uterus will
return to its prepregnancy state in ____ weeks.
a. Six
b. Three
c. Four
d. Five
7. In her capacity to teach, the nurse describes the
changes of the uterus after childbirth to return to a
nonpregnant state as ____.
a. Catabolism
b. Subinvolution
c. Contraction of muscle fibers
d. Involution
8. Which of the following conditions does the nurse
explain to the patient te contributory factor that slows
uterine involution?
a. Full bladder during labor
b. Difficult birth
c. Prolonged labor
d. Infection during pregnancy
9. The nurse assesses the uterine fundus of the
mother. Which part of tge abdomen will the nurse
begin?
a.Symphysis pubis
b.Midline
c.Umbilicus
d.Sides of the abdomen
10. The First priority nursing intervention during the
immediate postpartum period is focused on ____.
a. Monitoring urinary output
b. Taking the vital signs every 4 hours
c. Observing postpartum hemorrhage
d. Checking level of responsiveness
Situation: Evelyn a multigravida, in her 20th weeks of gestation visited
the community clinic with complaints of dizziness, vertigo, and
heartburn. After the physical assessment, Nurse Harper finds the patient
as malnourished.
11. Iron supplementation was prescribed because of her low hemoglobin
level. Which statement, if made by evelyn, would indicate an
understanding of health instructions?
a. “My body has all the iron it needs and I don’t need to take
supplements.”
b. “Meat does not provide iron and should be avoided.”
c. “The iron is best absorbed if taken on an empty stomach.”
d. “Iron supplements will give green color to my stool.”
12. Evelyn was given iron as a supplemental vitamin to
prevent maternal anemia. She asks if its will not be
affected because she is regularly taking Vitamin C.
Which of the following would be the best response of
the nurse?
a. “Take two other vitamins separately.”
b. “Take the irons after a full meal.”
c. “Absorption of iron is enhanced with Vitamin C.”
d. “Drink milk when taking the iron supplement.”
13. Evelyn was also advised to take calcium
supplements on the 2nd and 3rd trimesters of
pregnancy. Which of the following would enhance her
intestinal absorption of calcium?
a. Fat-soluble vitamins
b. Proteins
c. Minerals
d. Water-soluble vitamins
14. Nurse Harper observes evelyn has a knowledge
deficit regarding fetal nutrition. Nurse Harper has to
explain that main source of nutrition for the baby is
which of the following?
a. Amniotic Fluid
b. Uterus
c. Placenta
d. Chorionic Villi
15. Nurse harper provides health instruction to the
patient experiencing heartburn. Which statement by
the patient indicates a need for further instructions? I
have to ___.
a. Drink milk between meals
b. eat, small, frequent meals
c. Avoid fatty or spicy foods
d. Lie down after eating
Situation: The giving of medication to a pediatric patient is a
responsibility of a nurse. Nurse Imelda has just been
assigned to the Pediatric Wards.
16. When giving medicine to pediatric patients, dosage
varies. Which opf the following should Nurse Imelda
consider?
a. Height and surface area
b. Size, surface area and age
c. Size, surface are, age and height
d. Size and surface area
17. The Head nurse checks Nurse Imelda's knowledge on
administering oral medications to pediatric patients. Which of the
following statements below should she choose as CORRECT?
a. A child's reaction to a dose ordered by a physician is not less
predictable han adult’s reaction.
b. When giving oral medication, the child as young as two years of
age cannot be taught to swallow drugs.
c. The child should be told to place the table in the middle of his
tongue and drink water to wash down the tablet.
d. The possibility of error is greater in the giving of medication to
children than to adults.
18. In infants and toddlers, which part should Nurse
Imelda often use for intramuscular injection to reduce
the risk of vascular and peripheral
nerve injuries?
a. Gluteus maximus
b. Dorso-gluteal
c. Deltoid muscle
d. Vasts lateralis
19. Administering medication intramuscularly can produce a
variety of serious adverse\ effects has been revealed in
comprehensive surveys of research reports. When asked by
the Head nurse what is the MOST common complication
that may arise, Nurse Imelda should mention __.
a. Abscess
b. nerve palsies and paralysis
c. Hematoma
d. muscle contracture
20. Prior to administering the drug ordered by the
pediatrician, Nurse Imelda needs to know if she is giving the
ordered medication to the right patient. The FIRST step is
____.
a. Check the patient's hospital bracelet.
b. Ask the parent/significant other to state name of patient
and birth date of patient.
c. Verify patient’s allergies with chart and with patient.
d. Compare medication order to identification bracelet.
Situation: Alaia, a patient with severe pre-eclampsia, is admitted to the hospital.
She is a students from one of the local universities, she insists on continuing her
studies while in the hospital despite being instructed to rest. The patient studies
approximately 10 hours a day and has numerous visits from fellow students,
family, and friends.
21. Nurse Isabelle is concerned about the patient's welfare and her ability to
comply with the doctor's instructions. What should be the APPROPRIARTE
actions?
a. Include a significant other in helping the patient understand the need for rest.
b. Instruct the patient that the baby's health is more important than her studies
at this time.
c. Develop a routine with the patient to balance her studies and her rest needs.
d. Ask her why she is not complying with the prescription for bed rest.
22. Patient Alaia, who seems to be irritated with the
nurse, said, "I don’t want to talk to you because you're
only a nurse. I will wait for my doctor." Which of the
following is an APPROPRIATE response by the nurse?
a. "I'm angry. with the way you dismiss me."
b. "So then you would prefer to speak with your
doctor?"
c. “I understand. I should call your doctor.”
d. "Your doctor prescribed this for us to do nursing care.
"
23. Nurse Alaia is now in a dilemma. This occurs when
_____.
a. There is a conflict between the nurse's decision
and that of his/her superior
b. choices are unclear
c. there is a conflict of two or more ethical principles
d. a decision had to be made quickly under a stressful
situation
24. Which of the ethical principles stipulates that the
nurse is responsible for the providing all patients with
care, attention and information?'
a. Beneficence
b. Advocacy
c. Nonmaleficence
d. Veracity
25. Which action by the nurse provides a safe
environment for a preeclamptic patient?
a. Maintain fluid and sodium restrictions.
b. Take off the room lights and draw the window
shades.
c. Encourage visits from family and friends for
psychosocial support
d. Take the patient's vital signs every 4 hours.
Situation: Part II of the training is the giving of the hypothetical
situation for application of what was taken during the didactic. A
group was given a scenario of a pregnant woman in the OB ward.
26. The scenario states that the nurse is discussing the nursing
process with a newly hired nurse. Which of the following describes
the planning phase of the nursing process?
a. Identify the nursing diagnoses
b. Gather information if the patient's problem has been resolved in
the evaluation phase
c. Review the patient's history during the assessment
d. Prioritize patient problems.
27. Nurse Jezyl one of the group leaders reviewed the steps of the
nursing process with the group. Which of the following data should
the nurse identify as objective data? (Select all that apply)
I. Respiratory rate is 22/min.
II.Feels pain after a 10-minute walk
III.Pain is rated as 3 on a scale of 10.
IV.Skin is pinkish in color, warm, and dry.
a. II and III
b. I and IV
c. III and IV
d. I and II
28. On the second day, the patient delivered an alive baby
girl. She complains of leg pain. The nurse took hold of the
patient’s chart. Ponstan 500 mg every 4 hours PRN for pain
was ordered and was given. After 40 minutes, the patient
was relieved. What step of the nursing process should the
nurse have conducted?
a. Assessment
b. Planning
c. Evaluation
d. Intervention
29. According to the nursing process, which of the
following actions the nurse takes if the pain does not
satisfactorily relieve?
a. Wait for more time for the pain reliever to take
effect
b. Collect additional data as to why the patient has
not been relieve of pain.
c. Teach the patient relaxation breathing techniques.
d. Refer to attending physician.
30. The nurse Trainor discusses the elements of
documentation. Which of the
following refers to being comprehensive and timely?
a. Complete and current
b. Accurate and concise
c. Organized
d. Factual
Situation: Patient Ellie,a 28 year old primigravida, is admitted to a birthing
center. She has been in labor with an interval of 5 minutes apart for 10 hours
now. Hypotonic contractions are observe by Nurse Nora. She feels more pain
in her back than in her abdomen, sonogram shows her fetus is “borderline”
large for gestation and in occipito-posterior position.
31. Nurse Nora observes that the Ellie's uterine contractions are irregular
in frequency and short in duration. Ellie screams in pain during contractions.
Which of the following actions is considered BEST for the nurse to perform?
a. Try to divert attention from pain.
b. Administer pain reliever as ordered.
c. Stay with the patient and offer her a back rub.
d. Document and report frequency and duration of contractions
32. The physician is considering augmenting her labor
with oxytocin. What would make Nurse Nora question
the use of of oxytocin for Patient Ellio?
a. She had an amniocentesis performed during
pregnancy
b. Her fetus is large for gestational age by a sonogram
c. Her membrane ruptured after only 1 hour of labor
d. Her blood pressure is slightly elevated above
normal not normal
33. Nurse Nora notices patient's uterine contractions are 70
seconda long and occur every 90 seconds when assessing
the frequency of her contarctins after she receives oxytocin.
What would be the nurse’s first action?
a. Give an emergency bolus of oxytocin to relaxed the
uterus
b. Discontinue the administration of the oxytocin infusion.
c. Increase the rate of client’s IV infusion
d. Ask client to turn to her left side and braths deeply.
34. Nurse Nora monitors the patient, knowing that which
finding indicates an adequate contraction pattern?
a. Three to 5 contractions in a 10-minute period, with
resultant cervical dilatation
b. Four contractions every 5 minutes, without resultant
cervical dilatation
c. One contraction every 10 minutes, without resultant
cervical dilatation
d. One contraction per minute, with resultant cervical
dilatati
35. Which of the following nursing measures would
the nurse LEAST CONSIDERS to Patient Ellie with
oxytocin drip?
a. Know: how to recognize potential adverse
reactions.
b. Administer oxytocin drug with caution
c. Monitor patient closely when infusing oxytocin
d. Inform patien about potential complication.
Situation: Miriam on one year of age, is admitted due to
pneumonia. She has IV antibiotics, antipyretic, decongestant
and vitamins medications. She also is under oxygen therapy.
36. Nurse Messy has been worried about Miriam's refusal to
take her oral drug. How will she handle the situation?
a. Leave the child alone
b. Seek the help of the mother in giving the oral drug.
c. Mix the drug with milk to cover up the unfavorable
taste.
d. Get angry with the mother and the child.
37 . As a one-year-old, Nurse Messy understands the
reason (s) why Miriam continuously refuse to take her
drug. It is beacause it is normal for her age to ___.
a. have separation anxiety.
b. internalize the attitudes of others.
c. utilize magical thinking.
d. be negativistic in all matters.
38. The BEST way to administer oxygen on Miriam is
by ____.
a. hood
b. face Mask
c. Incentive Spirometer
d. nasal catheter.
39. For the IV antibiotic therapy of Miriam, the MOST
common gauge used for IV cannula is gauge ______.
a. 20
b. 24
c. 22
d. 18
40. What IMPORTANT evaluation parameter should
Nurse Messy observe that would show improvement
in Miriam's condition?
a. Absence of fever.
b. Absence of chest indrawing.
c. Respiratory rate of 45 beats per minute,
d. Respiratory rate of 55 beats/ minute.
Situation: Ashley a postpartum patient, who has delivered a
stillborn wants leave the hospital without a physician’s orded. The
patient is still hooked to an intravenous fluid (IVF) and le on closed
postpartum monitoring.
41. To avoid lability, which of the following 19 an APPROPRIATE
action by nurse Valerie?
a. Notify nursing supervisor of the patient’s plans to leave
b. Arrange medication prescriptions at the patient’s preferred
pharmacy.
c. Notify directly the attending obstetrician.
d. Ask th epatient about transportation plas from the hospital.
42. Nurse Valerie informs patient Ashley on the need for
early ambulation. Which of the nurse’s instructions on
ambulation is incorrect?
a. Assist the patient from sitting to standing position.
b. Raise the head of the bed slowly to achieve sitting
position of th epatient.
c. Allow the patient to rise from the bed to a standing
position unassisted.
d. Assist patient to rise from lying to sitting position.
43. While waiting for a feedback from the nurse supervisor regarding the
patient’s desire to go home, nurse valerie opted to check on the patient. Upn
entering the room, she discovers that the waste basket is on fire. Sequence
the nurse’s actions in the options below.
I. Resume the patient.
II. Activate the fire alarm. R A C E
III. Close the door to confine the fire.
IV. Put off thr fire with fire extinguisher.
a. IV, II and I
b. I, II ,III and IV
c. I, II and IV
d. II, IV and I
44. After the fire was out off, the patient was found to
have absconded. What is the ethico-legal
responsibility of the attending nurse?
a. Autonomy
b. Nonmaleficence
c. Beneficence
d. Justice
45. Absconding is inevitable in any health care facility.
who will be informed IMMEDIATELY if the patient
found out absconded?
a. Attending physician
b. Security guard on duty
c. Resident on duty
d. Nursing staff
Situation: Catherine, 5 years of age, is admitted to the pediatric ward due to
severe otalgia, fever, and irritability. The mother informed Nurse Selma that
the patient had upper respiratory infection three weeks prior to admission.
The admission diagnosis is acute otitis media (AOM).
46. Nurse Selma conducts her INITIAL assessment on Catherine. The patient
keeps on crying and constantly pulls her right ear. What is her MOST
APPROPRIATE action?
a. Request parent to carry the child
b. Take Catherine's vital signs.
c. Refer to the attending physician.
d. Assess the description and frequency of pain.
47. Nurse Selma is preparing to administer Ofloxacin
eardrop on Catherine per Doctor's order. She needs to
hold the bottle with her hands to warm up the
solution to prevent dizziness for ___.
a. 5-6 minutes
b. 1 to 2 minutes
c. 3-4 minutes
d. 6-7 minutes
48. After washing her hands and gently cleaning any
discharge that can be removed easily from the outer
ear, Nurse Selma positions the child. Which of the
following steps follows?
a. Gently press the tragus of the ear four times in a
pumping motion.
b. Gently pull the outer ear
c. Drop the medicine into the ear canal.
d. Keep the ear up for five minutes.
49. Based on her knowledge on otitis media, Nurse
Selma recalls that children are predisposed to AOM
due to the following risk factors, EXCEPT ____.
a. absence of breastfeeding
b. Swimming
c. exposure to cigarette smoke
d. poor hygiene
50. To promote drainage and reduce pressure from
fluid, Nurse Selma's's nursing intervention is to have
the child assume any of the following positions,
EXCEPT
a. tilt head to side if sitting up
b. lie on the affected area
c. put the pillows behind the head
d. lie on the non-affected ear
Situation: Nurse Ester is rotated to the Pediatrics Ward. As
such, she need to review the principles and concepts of
human growth and development to better appreciate her
role as a professional nurse.
51. Being assigned to care for pediatric patients, Nurse Ester
should remember which of the following statements?
a. Toddler period ranges from 12 to 36 months.
b. An infant's tongue is smaller than the adult.
c. Early childhood period ranges from 3 to 7 years.
d. Breast milk provides complete infant nutrition.
52. While Nurse Ester was taking the temperature of
Baby Chooka, the mother asked Nurse Ester when
growth and development become more rapid. Her
answer should be, during at
months of life
a. Ten
b. Nine
c. Twelve
d. Eleven
53. It is vital for Nurse Ester to give concrete examples of
activities to stimulate gross and fine motor development.
Examples are, which of the following?
1 Push/pull
2 Use of scissors and pencil appropriately
3 Poking straws into holes
4 Stand on tiptoes if shown first
a. 1 and 2
b. 2 and 3
c. 3 and 4
d. 1, 2, 3 and 4
54.According to the world health (WHO), sucide has
become a global phenomenon. When taking care of
emotionally disturbed adolescent patients, Nurse Ester
should be alerted with warning signs which often occur
for at least one month before a suicide attempt,
EXCEPT
a. increase in initiative
b. verbalization of suicidal thoughts.
c. Crying
d. Sleep disturbances
55. During one of the nursing rounds, the Pediatric
Ward Headnurse asked Nurse Eater the inclusive ages
considered as the transition from childhood to
adulthood but sometimes graduation. Her CORRECT
answer should be ____.
a. 15 to 18
b. 12 to 16
c. 11 to 18
d. 13 to 18
Situation: In a birthing station, five postpartum mothers
delivered 2 hours, 4 hours, and 6 hours ago, respectively. All
of them are multigravida patients. Adalynn, the nurse educator
opted to
conduct health education on a postpartum hemorrhage.
56. Nurse Adalynn explains to the mothers that early indication
for hypovolemia caused by postpartum hemorrhage is
a. increasing pulse and decreasing blood pressure
b. altered mental status and level of consciousness
c. dizziness and increasing respiratory rate
d. cool, clammy skin, and pale mucous membranes
57. The nurse educator Adalynn reviewed the risk
factors for postpartum hemorrhage for the
mothers. Which of the following factors IS NOT
included ____?
a. ruptured uterus
b. uterine atony
c. overdistended uterus
d. retroversion of the uterus
58. During the norml postpartum course, when
would the nurse expect to note sexual activity.
Which of the following information should the
nurse tell the patient on resumption of sexual
activity?
a. Immediately after the delivery
b. 4 days after the delivery
c. When the client's bladder is full
d. The day after the delivery
59. A postpartum patient asks nurse Adalynn when
she may safely resume sexual activity. Which of the
following information should the nurse tell the patient
on resumption of sexual activity?
a. In 2 to 4 weeks
b. At any time
c. After the 6-week physician check-up
d. When her normal menstrual period has resumed
60. Nurge Adalynn discusses the possibilities of future
postpartum hemorrhage with the patients. Which of
the following increases the absorption of vitamin K?
a. Proteins
b. Carbohydrates
c. Minerals
d. Fats
Situation: During the Nurse's rounds, the Headnurse noticed
that the Intake & Output sheets have not been filled up.
61. Based on the findings, what should the Headnurse do?
a. Ask the staff nurses the reasons for the failure to
properly fill up the Intake & Output flow sheet.
b. Give the staff nurses first warning.
c. Conduct a needs assessment.
d. Review the Orientation Program.
62. The Headnurse decided to coach her staff nurses.
One of the questions she raised was what fluids
should be excluded in the I & O flow sheet. The
CORRECT response should be, which of the following?
a. Intravenous fluids
b. Gelatin
c. Solid Foods
d. Beverages
63. The Headurse emphasized to the staff nurses what
NOT to be included under the output list. The answer
should be, which of the following?
a. Drainage from tubes
b. Solid/hard feces
c. Urine
d. Vomitus
64. The BEST time to record the Intake and Output is
____.
a. during endorsement
b. after endorsement
c. right before endorsement
d. anytime before duty
65. A patient's I a 0 is vital for patients with Chronic
Heart Failure. The MAIN purpose
of recording accurately the I & O of such patient is to
_______.
a. determine if client is improving or not
b. find out if there is still water retention in the
interstitial cells
c. detect cardiac overload
d. determine weight gain/loss
Situation: The group of nurses assigned in the delivery room is
interested in conducting a study on the experiences of pregnant
women in labor. They are thinking of qualitative research.
66. In the presentation of results of qualitative research, the
nurse researcher uses as a reference in the write-up the _____
person.
a. first
b. second
c. fourth
d. third
67. Nursing, as a human science, deals with the critical
and fundamental differences in attitude toward their
respective phenomena. Which of the following is an
aim of human sciences?
a. Construct prediction.
b. Seeks causal explanation.
c. Sets control
d. Makes meaningful interpretation.
68. The group was observant as to the activities taking
place in the delivery room. One of the activities
involved social processes, which can be better
explored. which of the following qualitative research
method should be used?
a. Grounded theory
b. Historical research
c. Descriptive Phenomenology
d. Case study
69. After the data analysis of their study, experiences
of pregnant women in labor, they returned to the
participants to determine the accuracy of the emerged
themes. Which criteria of trustworthiness is the group
doing?
a. Confirmability
b. Credibility
c. Transferability
d. Dependability
70. The group used an audio recorder to capture what
transpired during the interview. After the transcription, which of
the following action is APPROPRIATE for the group to do with
the audiotape?
a. Keep the audiotape in a vault and dispose of it a year after.
b. Submit the audiotape to their research adviser.
c. Throw it in the trash bin immediately after it was used»
d. Post the recording on their university research website for
others to listen.
Situation: Marie, OB-GYN head nurse, conducted an
in-service program on staff development.
71. Head nurse Marie, discussed that the MOST
frequently neglected area in management is
a. Managerial knowledge
b. Professional development
c. Clinical skill
d. Successful communication
72. A critical component of the supervisory process is
delegation. Which of the following is the MOST empowering to
staff?
a. Effective delegation does not require nurses to know the
abilities and weaknesses of their staff
b. Delegation frees the manager to do other taske while
empowering staff.
c. Delegation fosters the responsibility of staff while increasing
professional growth.
d. Delegation starts at top management down to subordinates
73. Head nurse Marle discussed negotiation. The focus
of negotiation is to create a ____.
a. soothing situation
b. third-party consultation
c. trade-off
d. win-win situation
74. Supervision occurs after delegation. What is the
PRIMARY purpose of supervision?
a. Influences the organization’s approach in
recruitment, promotion and personnel evaluation.
b. Improves staff compliance with policy and
procedures.
c. Assigns appropriate work tasks to the best-qualified
d. Enhances the delivery of quality nursing care.
75. Delegation involves the transfer of care to an
individual. What is the BEST criterion when delegating
staff?
a. Responsibility
b. Adaptability
c. Flexibility
d. Competence
Situation: Therapeutic communication promotes understanding
between the sender and receiver. Nurse Gary should be abreast with the
common therapeutic techniques if he wants his nursing care to be
effective and achievable.
76. When a patient says,"I am not sure if I should undergo colonoscopy
or not as I am scared. Which of the following is the MOST appropriate
communication technique that Nurse Gary should use?
a. A. Touch
b. B. Clarifying
c. C. Restating
d. D. Silence
77. When a patient says, "Whenever I see my husband
visit me, I feel depressed". Nurse Gary says, "Your
husband depresses you?" The therapeutic
communication is which of the following?
a. Restatement
b. Focusing
c. Focusing
d. Seeking clarification
78. When a Nurse Gary says to the patient, “Tell me
more about your experience when experience when
you had the colonoscopy”. Which of the following
therapeutic techniques is Nurse Gary using?
a. Focusing
b. Clarifying
c. Encouraging elaboration
d. Restating
79. When nurse gary says, “Tell me more about about
your experience. I wish to hear about…”, which of the
following therapeutic techniques is Nurse Gary using?
a. Restating
b. Seeking clarification
c. Open-ended questions
d. Summarizing
80. When Nurse Gary tells the patient, "You will be
wheeled in to the OR and will be hooked to an IVF
where the anesthesia will be given intravenously."
Which of the following therapeutic communication
techniques is Nurse Gary using?
a. A. Clarification
b. B. Summarizing
c. C. Giving information
d. D. Reflection
Situation: A pediatric patient 12 years old, is edmitted to the
Private Room with a tracheostomy tube.
81. Since the Staff Nurse assigned to the patient does not
have any experience in caring for a patient with
tracheostomy tube, who among the following should NOT
do the care?
a. Medical Resident
b. Medical Intern
c. Charge Nurse
d. Mother of child with care of tracheostomy tube
experience
82. The otolaryngologist arrives to change the
tracheostomy tibe.WHich of the following should the
Nurse collaborate with for the appropriate
equipment/supplies needed in changing the
tracheostomy tube,
a. Emergency Department
b. Central Supply Unit
c. Anesthesia Department
d. Operating Room Department
83. To assure that Nure Mica will learn the proper way
of caring for patients with tracheostomy tube, the
Headnurse should collaborate with who among the
following personnel for the training?
a. Asst. Chief Nurse for Clinical
b. Chief of Untt
c. Asst. Chiel Nurse toY Education & Training
d. Chief of Clinics
84. The Otolaryngologist ordered a change of-the
tracheostomy tube ties? Who among the following
should the doctor collaborate with?
a. A. Medical Intern
b. B. Medical Resident
c. C. Nursing Aide
d. D. Staff Nurse
85. The skill of suctioning using a single-use catheter
for tracheostomy is more safely performed with which
of the number(s) of assistant ?
a. A. Four
b. B. Two
c. C. Three
d. D. One
Situation: Josephine, a multiparous patient is admitted due to
labor pains which started an hour ago. During the vaginal
examination, the nurse noted the complete dilatation of the
cervix and effacement is 100 percent. The patient is in true
labor pains.
86. Which of the following problems with labor and delivery is
completed in less than 3 hours?
a. Precipitous
b. Preterm
c. Induced
d. Prolonged
87. Patient Josephine was referred to the physician,
routine blood examinations were taken. After
reviewing the serum electrolyte levels an order of
isotonic intravenous (IV) infusion was prescribed.
Which IV solution should the nurse prepare?
a. 5 percent dextrose in water
b. 0.45 percent sodium chloride solution
c. 10 percent dextrose in water
d. 3 percent sodium chloride solution y
88. The patient during labor would anticipate some
emotional support. Which of the following nursing
interventions should Nurse Sarah provide to keep the
patient calm?
a. Giving praise for her the sense of satisfaction regarding quick
labor.
b. Support in maintaining a sense of alcohol
c. Explanation of the effect of labor on the newborn.
d. Allowing the patient to express pain and anxiety
89. Patient Josephine asks why her labor is much
shorter compared to previous deliveries. Which of the
following is the BEST RESPONSE?
a. Onset of contraction was gradual.
b. Multigravida patient has shorter labor
c. Cervical lengthening was longer.
d. Induction of labor was done.
90. Nuree Sarah reads the physician's prescription to
administer methylergonovine maleate (Methergin)
intramuscularly after delivery. The rationale for giving
this medication is which of the following?
a. Reduces the amount of lochia drainage.
b. Prevents postpartum hemorrhage
c. Decreases uterine contractions.
d. Maintains normal blood pressure.
Situation: Jose, 10 years old, has bronchitis. He needs
oxygenation 4L/min per doctor's order.
91. The first standard step-in oxygen therapy that the
nurse should do is, which of the following?
a. Prepare the patient for the oxygen treatment
b. Check the chart for ordered flow rate and oxygen
delivery method.
c. Gather all the equipment and supplies.
d. Assess patient's condition.
92. In planning for Jose's oxygen therapy, the nurse
shall consider which of the following, EXCEPT _____.
a. need for a humidifier.
b. length of tubing.
c. determine the age of Jose.
d. manner of administering oxygen, continuous or
intermittent.
93. The PRIORITY nursing action of the nurse for Jose
due for oxygen therapy is ______.
a. attach the humidifier and connecting tubing to the
oxygen delivery device.
b. connect the flow meter to the pipe in oxygen
outlet
c. turn on the oxygen
d. check the flow.
94. What PRIORITY precautionary measure should be
done by the nurse duringthe oxygen therapy?
a. Limit visitors.
b. Attach "No Smoking" signage
c. Check humidifier's water regularly
d. Connect belt to oxygen tank.
95. One evening, Jose complained of dyspnea despite
continuous oxygen therapy. What should be the
nurse's INITIAL intervention?
a. Give PRN medication.
b. Refer patient to the physician
c. Assess the patency of the tubing.
d. Re-assess the patient.
Situation: Headnurse Wilma has been encountering errors in
documentation and records management based on her review of the
nurses' notes in the patients' charts. To solve the issue, she decided to
conduct a lecture on proper nursing documentation and management of
records.
96. At the start of her lecture, Headnurse Wilma asked the purpose of
the nursing process. Which of the following purposes is the CORRECT
answer?
a. Reduce the number of forms of the charte:
b. List the patients health problems.
c. Record the patient's progress.
d. Provide confidentiality of the chart.
97. One of the staff nurses was asked about the
principles to be observed when charting patient's
progress accurately. Which of the following principles
would be the CORRECT answer?
a. Statemente are qualified by the use of "seems' and
"appears"
b. Assumptions and conclusions are reported
c. Specific and definite words or phrases are used.
d. General statements and measurement are used.
98. Which of the following is NOT a characteristic of
charting?
a. Complete
b. Subjective
c. Objective
d. Accurate y
99. During nursing endorsements, the Kardex is used.
which of the following statements is NOT correct? It is
____.
a. kept up to date
b. a quick reference for current information about
the client.
c. Consists of folded card for each patient.
d. part of the medical record.
100. A sample of an error in charting was shown by
Headnurse Wilma. Which of the following is the
CORRECT solution to remedy the error?
a. Recopy the sheet and destroy the original sheet
b. Use a single line to cross out the error, the write
the date, time and sign the correction made.
c. Use correction fluid to erase the error
d. Use eraser to remove the wrong entry
Situation 1 – Research is vital endeavor nurses must
engage into in order to contribute to nursing science.
101. When nurse researcher collects data at more
than one point over extended, which design is
applied?
a. Cross-sectional
b. time-related
c. time-sequenced
d. Longitudinal
102. If research study involves an interventions and
binding which research design is being referred to?
a. Non-descriptive
b. Phenomenological
c. Experimental
d. Descriptive
103. Which of the following statement is LEAST
descriptive qualitative research design ?
a. Researchers become involved
b. Gather one data from collection strategy
c. It is flexible and elastic
d. Strives for an understanding of the whole strategy
104. Qualitative researchers should choose their
participants who can best meet the objectives of the
study. Who of the following BEST qualifies?
a. Cooperatives persons in the community
b. Those readily available thus convenient for the
researcher
c. Able to articulate and reflect on the phenomenon
that they experience
d. Persons referred by friends
105. A “full understanding” in research should be
understood by the nurse researcher as ______.
a. ensuring that the participants are not placed at
risk.
b. explaining that the study including risk and ben
c. The right to decide voluntarily
d. not exploiting information shared by participants.
Situation 2 – Management of records is very vital in any
health care facility. The nurse must ensure that there is due
diligence in the task.
106. Nurse Gay is assigned in medical unit. She is guided in
documentation, she should use abbreviation that is
________.
a. used automatically to save precious time
b. reduced to the minimum in all units
c. approved standard list by the hospital
d. not used at all because it can be misinterpreted
107. One error in record-keeping is eligible in
handwriting. What is the APPROPRIATE action by the
nurse in this situation?
a. Request the senior nurse to read the order for you
b. Let the resident-on-duty in the nurses station
interpret it.
c. Call the physician who made the order
d. report the lapse to Quality Assurance Committee.
108. When the nurse commits an error in the progress notes
the BEST action she should do is________?
a. cross the error many times to ensure it can no longer be
read and sign.
b. delete the erroneous phrase or sentence, make the
correction over it, and sign.
c. put a line across the sentence, make the correction over
it.
d. erase whatever is in error using the rubber eraser and
sign.
109. Which is not correct statement regarding record-
keeping?
a. failure to do it could be evidence to professional
misconduct
b. it is optional task to be done when circumstances
allow.
c. it is a tool in professional practice that helps
provide quality care.
d. it is part of professional duty of the nurse
110. The QA nurse conduct a regular audit of the
medical records. PRIMARY purpose of conducting
audit in a health facility is?
a. identify errors made by health personnel
b. identify areas of improvement
c. ensure that the standards are met
d. promote risk management
Situation 3 – Health education to bong and His family is set
up prior surgery. A program of weight gain aims for a high
protein and high calorie diet. The nurse prepare the health
education plan.
111. The nurse ensures, which of the following should be
present and be cooperative in the educational program ?
a. Patient, students nurses and interns
b. Patient, family and significant others
c. Head nurse and Family
d. New staff nurses and nursing aides of the unit
12. The nurse must include in the education plan, which of the
following components? (Select all that apply.)
I. Objectives
II. Content and allotment
III. Teaching and Learning resources
IV. Evaluation Parameters
a. II, III, IV
b. I, III, IV,
c. I, II, III, and IV
d. I, II, and III
113. To have a simplified and more understandable
implementation of the plan of the nurse presents it
with use of _________.
a. printed content in cartolina
b. a lecturer
c. a co-worker
d. colored pictures
114. Before education plan of the staff nurse can be
finalized and implemented, it is BEST that it is
reviewed by the _________.
a. Nurse Supervisor
b. Medical Director
c. Head Nurse
d. Chief Nurse
115. During the implementation process, the nurse
should ensure a _____ for a better assimilation of the
teachings.
a. serious lecturer
b. lecture to start at 11:00AM
c. conducive time and place
d. neophyte as sharer
Situation 4 – nursing student myra decides to a qualitative
phenomenological on how the stigma of AIDS affects the
patients. She has previously identified 6 participant: 3 teenage
boys and 3 teenage girls.
116. What is the BEST way of Myra to collect data from these
participants?
a. Focus group discussion
b. Survey, questionnaire
c. individual interview
d. Observation
117. What kind of sampling method should be apply?
a. Network
b. Random
c. Stratified
d. Purposive
118. The statements of the findings of the study that will be
formulated by Myra should be by ?
a. summarizing the sharings of the participants of both
sexes
b. identifying the answers of the males and females by
percentages
c. describing answers of the males and females by
percentages
d. extracting meaning and themes from significant
statements
119. Informed consent in this study will be obtained
by Myra from the ________.
a. six participants only
b. Parents only
c. six participants and available relative
d. six participants and their parents
120. What is NOT important for Myra to do when
listening to tape recordings?
a. Do the listening as soon as possible after the
interview
b. Note for the voice tone and voice inflection
c. Listen when she feels the motivation for a more
productive time
d. take notice of the pauses of the participants.
Situation 5 – Communication is very important in a nurse-
patient interaction relationship.
121. It is not enough for the nurse to listen, but she has also
to validate what she has heard. The important of validation
are the following except:
a. perception influence the interpretations of a message
b. Most of the patient are cognitively impaired
c. Eye contact does not necessary send same message
d. assist clarifying thoughts
122. To be more responsible, a nurse needs to
understands the element of the communication
process. When she initiates interpersonal
communication, the element involved is ?
a. Referent
b. Sender
c. Message
d. Channel
123. Should the nurse encounter patients who are
stressed due to their health condition the best way to
communicate is through which of the following?
a. Sympathizing
b. Empathizing
c. Sharing
d. Listening
124. The reason for the nurse wishing to enhance
his/her communication skills is to be able to establish
rapport, except ____.
a. brings about change to promote-well being of
patients
b. decreased incidents of legal problems
c. gets better evaluation rating of care and delivery
d. generates threat between the nurse and the
patient
125. When nurse interacts with patients face to face
such as getting information during the assessment
phase of the nursing process, the level of
communication is which of the following ?
a. intrapersonal
b. interpersonal
c. public communication
d. Verbal
Situation 6 – It is necessary that records are well recorded and
properly if they are to serve the organization and the requesting
public well.
126. Incident Reports IRs shall be collected for the day and due
investigations scheduled by the Quality Department. Upon
completion the investigation, the IRs?
a.must be completed and stored on the open cabinet
b.can be stored on the table top for easy retrieval.
c. must be summarized monthly and stored in secured cabinet
d.classified by date so they can be easily accessibility
127. The patient record (charts) are collected every
three nights from the various departments. The night
nurse is EXPECTED to do the following EXCEPT,
________.
a. ensure the correct order of the chart
b. see the completeness of the chart
c. bind the charts as they are
d. tape or repair torn pages
128. When patient record reach the Medical Records,
the assigned staff will ______.
a. store the charts In their respective shelves
b. check the completeness of the charting of the
doctors and nurses
c. bind the chart immediately
Separate medicolegal Carts
129. The charts are stored in the Medical Records or
storage room for least __ years.
a. 3-5 years
b. 1-5 years
c. 5-10 years
d. 1-3 years
130. How many years are medico-legal charts stored?
a. 8 years
b. 10 years after the case is closed
c. 5 years
d. 10 years
Situation 7 – Health Education on HIV-AIDS has been massive in the
years prior, yet patients and their relatives still have a number of queries
and misconception about it. Lerma, a young mother of 34, has been
recently diagnosed of the diseased.
131. Lerma is aware that there is mother-to-child transmission of HIV-1.
She becomes concerned and ask the nurse when it specifically happens.
The nurse answer that it can occur in the following circumtances, EXCEPT
_____.
a. during breastfeeding
b. during casual contact
c. at the time of delivery
d. In utero
132. Lerma would like to know on how to limit further
exposure to more HIV virus by using preventive
measures. The nurse informs her that the highly use
effective male condomthat can decrease the
transmission of HIV is?
a. non-latex
b. latex
c. polyurethrane
d. lambskin
133. Patient Lerma has CD4 lymphocyte count which
below 200 cells/cumm.
She then ask what that means. The nurse answer that:
a. the results stills fall within normal limits
b. She is in Stage 3 HIV-AIDS
c. it is slightly below normal there is nothing to worry
d. it is worrisome result but immediate attention is
not necessary
134.The nurse counsel Lerma that the prevention of
HIV infection that is not usually realistic is which one
of the following?
a. HIV testing
b. Behavioral interventions to reduce risk
c. Total abstinence
d. Linkage to a treatment center
135. Nurses are at risk of HIV exposure, Post exposure
prophylaxis (PEP). DOES NOT include one of the
following?
a. Take 2-3 anti-retroviral drugs, as prescribed.
b. Drugs must taken for 28 days
c. Drugs must taken for a least a week
d. Take the medicine within 72 hours of exposure
Situation 8 – The Quality Department has received numerous
complaints, some of them on patient falls.
136. Nonah who is 86-year-oldpatient is admitted for fever fall from
the bed despise the presence of the watcher. The head nurse was
concerned since a fall of protocol has been formulated for some
time now. To avoid similar incident of fall. What is the APPROPRIATE
thing for the head nurse to do in this regard?
a. Interview the patient
b. Interview the nurse-on-duty
c. Investigate everyone
d. Do a root cause analysis
137. The nurse informed the Head Nurse that the lock in the side
rails does not work properly at times and might have gotten loose
in the night thus the incident fall. What is the APPROPRIATE thing
for the Head Nurse to do in this regard?
a. Penalizes all the nurses for not having not report such defect
b. Make a memo to the Maintenance Department to check
involve bed and the rest of the beds
c. Punish the nurse-on-duty for not reporting such observation
before the incident
d. warn everyone this is not going to be tolerated in the future
138. The quality improvement officer-in-charge of the
units plans to conduct a meeting with the staff. The
MOST important thing to tackle is to ________.
a. inform them their punishment
b. Review the protocol
c. Inform them of their lapses
d. Scold those involved
139. What is the INITIAL action that the nurse should
do immediately after the fall mitigate the situation?
a. Document the incident right away
b. Phone the Head Nurse to report the incident
c. Wait for the head nurse
d. Have a doctor assess the patient immediately
140. What lesson will the nurse learn from this
incident
a. Tell the others to cover her up
b. Safety-first report even trivial but relevant
observations
c. Deny any errors or omission
d. Never get caught on her omission
Situation 9 – Nilda, 58 years of age, was brought to the E.R
because of the numbness on her left face and arm and a
confused mental state. The ER doctor made an initial
impression of ischemic stroke.
141. Nilda wonders how she develop the manifestation of
ischemic stroke. The explain that there is _______.
a. extravasation of blood into the brain
b. possible presence of cerebral aneurysm
c. Vascular occlusion in cerebral blood flow
142. The nurse knows the visual-perceptual
disturbance can occur in stroke. When patient Nilda
manifest hemianopsia, she has _______.
a. Inability to performed everyday movements and
gestures
b. blindness in half in the visual field
c. difficulty speaking
d. inability to understand spoken language
143. the nurse knows the initial diagnostic test that is
ordered for stroke is ______.
a. Carotid ultrasound
b. 12-lead ECG
c. Magnetic resonance Imaging (MRI)
d. CT – SCAN
144. The ER nurse anticipates that the thrombolytic
agent would be ordered to the treat ischemic attacks.
Knowing the actions of thrombolytic, the nurse must
particularly alert for which adverse reaction?
a. Formation of blood clots
b. Bleeding
c. Early onset of infection
d. Allergies
145. Patients Nilda complain of shoulder pain. The nurse is
aware of the she is prone to have adduction of shoulder. A
nursing intervention for this is to _______.
a. position distal joint higher than proximal joint
b. Place the pillow under the arm to keep the arm close to
the chest
c. Position the fingers so they are barely flexed
d. Place one pillow in the axilla to keep the arm away from
the chest
Situation 10 – Emmy, 22 years of age is midwife in the OB
Ward is now complaining of contact dermatitis from gloves.
146.Patient like Emmy who experienced delayed
hypersensitivity to latex FREQUENTLY complains of ______.
a. Flushing, bronchospasm
b. Urticaria, Laryngeal edema
c. rhinitis, conjunctivitis, blisters
d. papules, vesicles, pruritus
147. The nurse knows that the diagnosis of contact
latex allergy is based on history and ?
a. Latex specific IgE
b. finding IgE in serum..
c. skin patch test
d. ELISA
148. Latex allergy can be a type I IgE-mediated
immediate hypersensitivity to plant proteins from
latex of rubber. It can manifest in its most severe form
as _______.
a. Pruritus, erythema and swelling
b. Asthma
c. Anaphylaxis
d. Blisters and other skin lesions
149. Type I IgE-mediates immediate hypersensitivity
reaction is promptly managed with _________.
a. theophylline
b. epinephrine
c. corticosteroid
d. diphenhydramine
150. The best prevention of contact latex allergy is
__________.
a. applying lotion before gloving
b. avoidance of latex product
c. avoiding rubberized goods
d. resigning from the job
Situation 11 – Sins of omissions and commission may committed by
the nurse in the cause of her duty. She must therefore be extra
careful.
151. The patient for the breast biopsy is very anxious and seemed
not to understand her ordered surgery, radical mastectomy. What is
the APPROPRIATE action by the nurse.
a. Call the supervisor to explain the procedure
b. Have the available resident explain the surgery further
c. Request the doctor to give the patient more information
d. Supply the information missed to be explained by the doctor.
152. The patient refused his intramuscular injection
but the nurse administered it anyway. What can the
nurse may accused of?
a. Moral distress
b. trespass to person
c. Assault
d. Battery
153. The staff nurse was doing prescribed modified
steam inhalation to a pediatric patient which resulted
to burns. What is NOT relevant statement to
established negligence?
a. There is a duty care
b. There is breach in the standard
c. There is breech caused the harm
d. It was verbal order by the physician
154. Staff nurse A told her co-workers that the staff B
is suffering from gonorrhea. What can staff A be sued
for?
a. Defamation
b. Slander
c. Discrimination
d. It was a verbal order by the physician
155. The surgical patient, a Jehovah’s witness,
reiterated non-acceptance to a blood transfusion
intraoperatively. What case can be filled by the
patient?
a. Moral distress
b. Battery
c. Trespass to person
d. Assault
Situation 12 – Nurses must closely adhere to the
ethical principles and rules and not only to the laws.
156. when the nurse ensures that the patients have
consented to all treatments and procedures, she is
TRUE to which ethical principle?
a. Fidelity
b. Beneficence
c. Veracity
d. Autonomy
157. If the nurse will refuse to perform duties for
which she is not qualified, she is practicing?
a. Veracity
b. Beneficence
c. respect
d. non-maleficence
158. The code of ethics stipulates that human is inviolable.
Which statement CORRECTLY translate the principle to the
situation of the FILIPINO nurse as a professional?
It is okay to participate in euthanasia’s provided there is
doctor’s order.
a. participation is permissible when patient, family and
doctor have written agreement on it
b. After the patient, doctor and hospital administrator have
agreed, nurses may choose to participate
c. Nurses shall not participate in euthanasia
159. When the physicians insist that his cancer patient
undergoes, radiation, in addition to to chemotherapy
which is COTRARY to the patient’s and family’s wishes,
the physicians is exercising _________.
a. Veracity
b. autonomy
c. fidelity
d. paternalism
160. An Iranian was admitted to the hospital for the kidney
transplantation. He claim that his donor is a Filipino relative
as required by law. However it was discovered later that his
claim was not true. Should the doctor fail to act accordingly
to the wrong information, the nurse is obligated to refer the
case to, which of the following?
a. Medical Director
b. Administrator
c. Chief Executive Officer
d. Ethics Committee
Situation 13 – the nurse conduct health education on common
types of allergy with the parents of allergic children and adults with
hypersensitivity issues.
161. During the conduct of health education class. Which
communication skill involves active listening that is being used by
nurses to gain an understanding the patient’s message.
a. Clarifying
b. Respinding
c. Attending
d. Confronting
162. The nurse must alert to BARRIERS of
communication during the health education class so
that she can___________.
a. Use them when communicating
b. Communicate much better
c. Use them to enhance interactions
d. rationalized wrong styles of communication
163. The mother of the atopic dermatitis patient is very concerned
about scarring that will result from the child’s frequent scratching.
How will the nurse BEST communicate her reassurance?
a. asking the mother what she prefers: for the child to have scars or
he be unable to sleep
b. telling the mother matter of fact that scars will lighten as the
child grows older anyway.
c. tapping the hand of the mother while explaining that scarring
occurs only when lesions get infected
d. reminding the mother that beauty is only secondary to comfort
derived from scratching.
164. Because of the presence of skin lesions, atopic
dermatitis affect’s the patient’s self-esteem and his
willingness to interact with others. The nurse communicate
the nursing intervention by ___________.
a. Instructing the patient to go back to the primary
physician
b. Giving instruction and counselling on preventive
measures and treatments
c. referring the patient to the dermatologist
d. referring the patient to the psychologist
165. The adult patient who was receiving diphenhydramine
(benadryl) verbalized he was always sleepy and fears he
would sleep in the job and will get fired. The nurse will BEST
calm the patient by assuring him that his physician can
readily change his medicine to ________.
a. Chlorpheniramine (Actifed)
b. Brompheniramine (Dimetapp)
c. loratadine (Allerta)
d. Dimenhydrinate (Dramamine) how to effect good
communication
Situation 14 – Susie,5 years old is diagnosed with nephrotic
syndrome and manifesting massive proteinuria resulting to
decreased of albumin in blood.
166. The nurse understand that the passage of the protein in
the urine is the result of ____.
a. inherited kidney disorder
b. increased glomerular permability
c. rise in production of albumin
d. intrinsic kidney disease
167. upon clinical assessment, the nurse observes that
the OUTSTANDING manifestation of the patient is
_______.
a. weight gain
b. obesity
c. emaciation
d. Edema
168. The physical appearance of the urine of the
patient with nephrotic syndrome is COMMONLY?
a. Cloudy
b. clear
c. whitish
d. frothy
169. The patient with nephrotic syndrome is ordered
corticosteroids. Who of the following are NOT
ALLOWED in the patient’s
a. parents with diabetes
b. Relatives with upper respiratory tract infection
c. Visitors with mild asthma
d. personnel with allergy
170. Corticosteroids are one of the main therapies for
nephrotic syndrome. Which of the following
COMMON side effects should the nurses watch for
a. Loss of appetite
b. increased in body hair
c. Loss of weight
d. Lowering blood pressure
Situation 15 – Patient Reno, 53 years of age, is pale and
complains of easy fatigability. He has undergone complete
Blood Count CBC where abnormal cells were found. He was
diagnosed with acute lymphocytic leukemia (ALL).
171. The nurse ensures that the isolation procedure
APPROPRIATE for Reno is ?
a. standard
b. airborne precaution
c. strict
d. protective
172. Which of the following diagnostic procedures will
definitely establish the diagnosis for the patient Reno?
a. white blood cell count
b. complete blood count
c. bone marrow biopsy
d. hemoglobin and hemtocrit counts
173. When the thrombocyte counts falls below
20,000/cu mm, the nurse will expect that the
physician will order _________.
a. Complete bed rest
b. strict aseptic technique
c. platelet transfusion
d. limit visitors
174. on the basis of his leukocyte count, the nurse
instruct the patient NOT to do, which of the following?
a. Limit the number of staff entering the room
b. be in the private room with the door close always
c. received immunization with Live attenuated virus
d. Use antimicrobial soap when bathing
175. During the period of exacerbation, the patient
hemoglobin’s is markedly decrased. What instructions
by the nurse is APPROPRIATE?
a. Allow exercise as long as tolerated
b. Let patient be independent on self-care
c. Perform only activities of daily living
d. serve pork and liver barbeque
Situation 16 – Nurses must continually grow as a person and as a
professional
176. A newly licensed nurse employed in the tertiary hospital, you
are required to attend Continuing professional Development CPD
program. When the training program is the enhancement of the
competencies of nurses employed in the hospital, it is called?
a. self-directed
b. in-service training program
c. Informal training program
d. formal educational program
177. The professional career development of nurse
can be achieved through various ways, such as.
a. participating in political rallies
b. attending culinary courses
c. Attendance in socio-civic activities
d. engaging in CPD programs
178. When nurses are projected in a television
advertisement as sex symbols, What appropriate
action is expected from a concerned nurse?
a. go to the street to manifest displeasure of the
nurses portrayal.
b. Report to the concerned agency
c. condemn the issue in the radio program
d. keep your silence, it is the television station’s
prerogative.
179. to enhance the personality to the graduate nurse,
she/he may attend which of the following programs?
a. Gymnastics
b. Marathon training
c. Social graces and physical fitness
d. scuba diving
180. The nurse’s application to Canada has finally been approved and
she was advised to depart in three months. She is currently enrolled in
the graduate school. Moreover, her mother has just been discharged
from the hospital. Which of the following actions is BEST?
a. Inform family that the money spent in graduate school can be easily
earned in Canada.
b. inform the agency that she go anytime as they wish
c. share with friends that this is her scape from her sad life with her
family
d. Request the recruiter to give her more time to settle her personal
concerns
Situation 17 – patient Narding is diagnosed with stroke and suffer from a
number of deficits as a result of injury of his brain. His rehabilitation may be
long. Depending on the extent of brain injury.
181. Narding has been urinating on and off in bed which is possibly related to
a flaccid bladder and difficulty in communicating. The nurse become
concerned because he is showing signs and symptoms pressure sores due to
his immobility and the frequently wet beddings. The nurse decides to refer
the patient to the __________.
a. resident on duty
b. attending physician
c. infectious doctor specialist
d. supervisor-in-charge
182. Narding becomes unduly silent and keep to
himself after his stroke left him with left-sided
weakness. The nurse observes that the patients seems
really sad and shares the information to the physician,
who refers the patient to a ______.
a. psychiatrist
b. neurologist
c. psychologist
d. physiotherapist
183. The patient shared his concern about being able
to father a child after the stroke, especially that he has
only one child, a girl. He would like to have two boys
but he doubt his present sexual capacity . Who can
BEST help him along this erea.
a. primary consultant
b. burse
c. supervisor in charge
d. urologist
Situation :Nurse Kyla is a staff nurse in the medical ward. Most of her patients are
afflicted with intestinal and rectal disorders.
184. Upon assessment, which of the following differentiates Crohn’s disease from
ulcerative colitis?
A. Presence of bleeding: severe in Crohn’s disease while in Ulcerative Colitis
bleeding is mild.
B. Presence of diarrhea: severe in Crohn’s disease in ulcerative colitis it is mild
C. Affected area: Crohn’s disease is the descending while Ulcerative colitis is the
ascending colon.
D. Course of the disease: Crohn’s disease is prolonged and variable, Ulcerative
colitis has a remission and exacerbation Rationale: Bleeding and diarrhea is
more severe in ulcerative colitis since it is mostly characterized by bloody
mucoid diarrhea. Crohn’s disease presents as cramping of the right lower
quadrant since it affects the ASCENDING colon while ulcerative colitis affects the
descending. Crohn’s disease tends to be chronic than ulcerative colitis.
185. Narding seems forgetful, inattentive, and not
answering appropriately to some question posed. The
nurse anticipates that the consultant will need to ask
the professional help of the _______ for cognitive
improvement.
a. psychologist
b. psychiatrist
c. family Doctor
d. neurologist
Situation 18 – The nurse in the exercise of her profession
must adhere to the ethico-moral standards set.
186. Should the nurse administer the wrong medicine to the
patient, what APPROPRIATE ACTIONS is she expected to do?
a. Keep silent about it for the meantime, but closely
observed the patient.
b. Make a report to the supervisor through the head nurse.
c. Tell the patient that an error has been committed
d. Ask the doctor what to do
Situation: You are a nurse in Psychiatric Unit. The use of
therapeutic touch is an effective intervention in caring for
your patience.
187. Which type of therapeutic touch is used when you
assess skin turgor of the patient during physical assessment?
a. Friendship-warmth touch
b. Love -intimacy touch
c. Social-polite touch
d. Functional -professional
188. You gently guide a patient in going to her room.
This is the type of:
a. Social-polite touch
b. Love-intimacy touch
c. Friendship-warmth touch
d. Sexual-arousal touch
189. You put your arms around the shoulders of an
elderly patient. Which type of touch is this?
a. Love- intimacy touch
b. Functional- professional
c. Social -polite touch
d. Friendship- warmth touch
190. What type of touch is used when it involves tight
hugs and kisses between relatives
a. Love-intimacy touch
b. Friendship -warmth touch
c. Social -polite touch
d. Functional -professional
191. Which of the following is NOT a type of
therapeutic touch used by the nurse in providing care
to psychiatric patients?
a. Social-polite touch
b. Friendship -warmth
c. Sexual -arousal touch
d. Love -intimacy touch
Situation: Tommy is a 7 year old, Grade one kid, who is
diagnosed with Attention Deficit/ Hyperactive
Disorder (AD/HD).
192. Manifestations of ADHD are usually identified in
what situation or event?. When a child is
a. At home, by parents
b. With peers, during play
c. Enrolled in the education system
d. Is brought to a well baby clinic
193. The school nurse reports that Tommy frequently
exhibits the following behavioral manifestations of
ADHD, except:
a. Interrupt others and can't take turns
b. Moody and bad tempered behavior
c. Easily distracted and forgetful
d. Incorrect and messy work
194. Tommy tells the nurse, "I don't have friends
because I'm stupid." Which of the following nursing
diagnosis would the nurse identify for him?
a. Ineffective coping
b. Anxiety
c. withdrawal syndrome
d. low self esteem
195. Nurses may be privy to very personal information
of patients and should make every effort to make it
confidential, otherwise she can be charged of
_________.
a. negligence
b. malpractice
c. invasion of privacy
d. defamation
Situation 20 – Quality improvement must be embraced by every
health institution if it aims for safe and quality core. The Medical
Director of camiguin medical center made random rounds for five
consecutive days to all areas of the hospital to assess its services.
196. which of the following is NOT a characteristic of quality
improvement that the medical director is interested in?
a. The leader is the empowerer
b. Problem-solving is by everyone
c. The employee is treated as customer
d. Reacts to correct or bad situation
197. A risk is any event that causes problems or the
benefits of the health care institution. The Medical
Director knows the potential risks must be identified
across the hospital in order to prevent the following,
EXCEPT:
a. Financial loss
b. Incident reports
c. accidents
d. injuries
198. Based on patient survey, a member of complaints
have been tracked. Which of the following is not a
preventive activity in the practice of the Medical
Director’s risk management?
a. Postering good administration-personnel relations
b. Providing safe environment every time
c. Staff should not be defensive
d. Listen to the patient’s cue carefully.
199. In terms of therapeutics, which of the following
medications can be used for inflammatory bowel
diseases?
A. Corticosteroids
B. Atropine sulfate
C. Dulcolax
D. Maalox
200. Nurses usually complain they have no personal
life because of rotating shifts. The following are three
major ways to create personal time, EXCEPT
_________.
a. delegate work to others
b. fill every moment with tasks or chores
c. eliminate tasks that add no value
d. hire someone else to do the work
Situation 11 – Darwin, 35-year-old engineer met a vehicular
accident to work. He suffered head injury, responsive and admitted
at intensive care unit for close monitoring and management.
201. During nursing assessment, Darwin speaks a rambling manner
and to repeat words spoken to him. Which are the brain MOST likely
to be affected ?
a. Wernicke’s area
b. Broca’s Area
c. Foramen Magnum
d. Brodmann’s Area
202. The physician order to computerized transversed axial
tomogram (CAT) scan. Nursing preparation of the patient for this
procedures includes:
a. Explaining the vital signs will be monitored for 2 hours after the
examination.
b. reassuring that the CAT scanning in a noninavasive procedure.
c. Explaining that the spinal tap will be done so that a radioactive
isotope can be injected.
d. Telling patient that a radiopaque dye is injected into an artery in
the arm
203. The physician order to observe for EARLY signs of
increased intracranial pressures which includes
______________.
a. restlessness and change in level of consciousness
b. Elevated temperature and decerebrate posturing.
c. Rising blood pressure and bradycardia
d. widening pulse pressure and dilated pupils
204. All of the following signs indicate increased
intracranial EXCEPT?
a. Decreased level of consciousness
b. tachycardia
c. papilledema
d. Vomiting
205. The nurse noticed dressing is wet. Which action by the nurse
can be safely used to determined if the drainage contains
cerebrospinal fluid (CSF). What is the attending nurse should do?
a. Blot the drainage with sterile gauze pad and look for a clean wet
around the spot of blood.
b. Swab the orifice of the ear with sterile applicator and the
specimen in the laboratory.
c. obtain a negative reading for a sugar after testing the CSF with
Test Tape.
d. Gently sucsion the ear and send the specimen to the laboratory.
Situation 12 – Nurse Managers participates in quality improvement
projects to increase awareness and achieve better performance of
nursing team.
206. A professional practice system that manages clinical care of
patients across a continuum using managed care concepts and tools
is called __________.
a. Modular nursing
b. Differ0entiated practice
c. Case management
d. Primary nursing
207.what is the outcome of having sound clinical care
management by professional health care team?
a. It decreases patients’ length of stay
b. It diminishes collegiality between health care
providers
c. It increases cost of hospitalization
d. It contributes to duplication of services
208. During a staff meeting, the nurse manager present his
own analysis and problems and proposals for action to the
staff, inviting critique comments. Which answer indicates
the manager’s leadership style?
a. Laissez0faire
b. Autocratic
c. Participative Leadership
d. Democratic
209. Which ofnthe following is often associated with
concept of decentralized decision making in
managemnent?
a. team Nursing
b. Interdisciplinary Model
c. Shared Governance
d. Primary nursing
210. Some decisions are best made by the group
rather than by the nurse alone. What is the advantage
of group decision making?
a. Promote collective contributions of idea
b. Different ideas and opinions
c. Individuals opinions are influenced by others
d. Dependency is postered
Situation 13 – Glory, 23 – year-old evening cashier of seven eleven 24 hours
convenience store, was sexually abused by a jeepney driver while on her way
home from work one evening. She was brought to the E.R with bruises all
over her body. She was crying controllably and appears to be anxious.
211. Which of the following therapeutic communication should nurse Ann say
for Glory?
a. “You are upset, calm yourself first Glory. I can’t understand you”.
b. “ Can you identify your abuser?”
c. “ I know something terrible and horrifying happened to you”
d. Would you like to relate to me what happened?
212. In providing nursing care for Glory during her
acute stress reaction to rape trauma, Nurse Ann may
apply, which of the following?
a. Physical Assessment
b. Collaborate with community agency
c. Crisis intervention tecniques
d. Normal reactions to a devastating event.
213. Glor’s physical assessment is complete and physical
evidence has been collected. After three days, Nurse Ann
noted Glory to be withdrawn, confused and at times
physically immobile. How should Nurse Ann interpret this
behaviors?
a. Evidence that the client is a high suicide risk
b. Signs of depression
c. Indacative of the need for longer hospital admission
d. Normal reactions to a devastating events
214. Emergency care to be given for rape victims as follow:
I. If victims calls the hospital, tell her not to take a bath, wash or change
clothes, just go directly to the hospital
II. Provide privacy and be judgmental
III. Stay with the victim, focus on physical safety and emotional security
IV. Assist on pelvic examination to collect evidences as semen stains
a. I, III, IV
b. I, II, III
c. II, III, IV
d. I, II, IV
215. Nurse Ann wanted to become a patient advocate of
rape victims. The following RESPONSIBILITIES should she
note?
a. Isolate the patient fist to provide privacy while attending
to other patients
b. Call the press since this a legal case
c. Perform thorough physical assessment and document
objectively all evidences of rape.
d. Postpone the physical examination until the patient is
calm
Situation 14 – Head Nurse Alona ensures teamwork and
collaboration in her to achieve efficient shared decision-making and
open communication to provide safe patient care.
216. A nurse returns from vacation a finds a new model of I.V pump
attached to her patient. How should the nurse proceed.
a. Read the I.V. pump manual before caring for the patient .
b. refuse to care for the patient
c. Inform the charge nurse and ask her to provide an teaching
session about how to use pump.
d. Use the pump because it is somewhat like the old pumps on the
unit.
217. A nurse caring for 72-year old male patient who
requires insertion of a central venous cartherer. Who
is responsible for obtaining informed consent?
a. Physician who will insert the cathether
b. Charge Nurse
c. Attending Physician
d. The Nurse assisting with procedure
218. A nurse reports that a patient cough frequently after
taking anything but mouth. The dietician recommends a
swallow evaluation for the patient, in which the physician
participating in the team rounds writes the order. This is the
example of collaboration of client care ______.
a. with the ancillary care providers.
b. between the physician and the dietary department
c. with risk management team because of risk aspiration
d. among members of the multidisciplinary group.
219. Before delegating to the new nurse the task of
giving a shower to the paraplegic elderly , the charge
should FIRST ensure that the new nurse ___________.
a. Has demonstrated competency for the task
b. has received the assignment during endorsement
time
c. is supervised at all times
d. provides companion to the patient
220. which of the following task would be
APPROPRIATE for the nurse to delegate to nursing
aide.
a. assist a new postoperative patient to the
bathroom
b. Teach a patient on how to administer discharged
medications
c. Change a center line dressing
d. Assist the patient during meal time.
Situation 15 – Mr. ferrer, 42 years old, is admitted to the
hospital in semi - conscious state diagnosed with
cerebrovascular accident.
221. the nurse obtain history of patient’s present illness
from his family. What significant information can the nurse
gather from the patient’s family?
a. Consistent Hypertension and dizziness
b. palpitations and hypotension
c. Family history about illness
d. emotional response form past illness
222. The PRIORITY nursing care for Mr. ferrer during
the acute phase is to _________.
a. provide sensory stimulation
b. Maintain Respiratory And Cardiac Function
c. Prevent Contracture And Deformities
d. Maintain Optimal Nutrition
223. Part of nursing care plan is to observed Mr. ferrer
for signed of increased intracranial pressure. Which lof
the following clinical manifestation should
manifestation would indicate this condition?
a. tachycardia and drop in blood pressure
b. Bradycardia and rising in blood pressure
c. Bradycardia and drop in blood pressure
d. D. tachycardia and rising in blood pressure
224. Which of the following positions will be MOST
APPROPRIATE to Mr. Ferre’s care?
a. Head of bed elevated in a lateral position
b. head of bed elevated in supine position
c. right lateral position
d. left lateral position
225. Mr. Ferrer’s wife is very upset and ask if there is
any hope to recover from his condition? Which of the
following is the MOST APPROPRIATE reply by the
nurse?
a. “you must be patient, let’s hope for the best
outcome”.
b. “ you should never lose hope”.
c. It is too soon to tell what the outcome will be”.
d. “ actually, manifestation may even get worse”.
Situation 16 – Liela, 5 years old, was diagnosed as autistic
since she was 1 year old.
226. What behavior will nurse Raffy observed as
characterized by Liela?
a. Inappropriate behavior, poor attention apan with
impulsivity
b. Negativistic hostile and defiant behavior
c. failure to develop to interpersonal skills
d. anxiety induced involuntary stereotype motor
movements
227. At her age, liela is in what stage of social
development?
a. Initiative vs. Guilt
b. Trust and Mistrust
c. Industry vs. Inferiority
d. Autonomy vs, shame & doubt
228. Nurse raffy recognize which of the following as a
COMMON behavioral sign of autism?
a. Clinging behavior toward parents
b. Early language development
c. Indifference being hugged or held
d. Creative imaginative play with peers.
229. the BEST nursing intervention that Nurse raffy
can use to provide trusting relationship with an
autistic liela is to ___________.
a. convey warmth through touch
b. Early language Development
c. explain to the child activities and routines
d. Provide a structured environment
230. Which pharmacologic treatment is APPROPRIATE
for liela’s temper tantrum, aggressiveness, self injury,
and stereotyped behavior ?
a. Clonidine (catnapers)
b. Naltrexone ( Re Via)
c. Clomipramine (Anafranil)
d. Haloperidol (Haldol)
Situation 17 – patient safety remains a global health care
challenge. There are basic principles of infection controls.
These includes standard precaution and transmission based
precaution questions.
231. Which of the following is considered the MOST
important in infection control?
a. Personal protective clothing
b. prevention of infection associated with catheter
c. safe use and disposal of sharps
d. hand hygiene of health care staff
232. Which mode of infection transmission is due to
splashes of blood/body fluids into the mucosa or
contamination of non intact skin with infected blood
and body fluids?
a. ingestion
b. airborne
c. inoculation
d. Direct/Indirect contact
233. which mode of infection transmission is due to
microorganism being transferred to other patients
from contaminated equipment's and via the hands of
nurses.
a. ingestion
b. Airborne
c. inoculation
d. Direct/Indirect contact
234. What mode of transmission is due to
contaminated food and water being consumed?
a. inoculation
b. direct/indirect contact
c. ingestion
d. airborne
235. Which of the following is NOT a standard
precautions?
a. respiratory hygiene
b. Injection safety
c. personnel protective equipment
d. Hand hygiene
Situation 18 – The nurse abides with ethic moral principles.
236. When the nurse placed the patients is the restraints
before using other methods of intervention, she/he violated
the patient’s rights to ______________.
a. receive confidential and respectful care
b. provide informed consent
c. personnel protective equipment
d. refuse treatment
least restrictive environment
Receive Tx in the
237. Which of the following actions is a violation of
psychiatric patient rights?
a. Paranoid patient with delusion about his family is told
that if he makes a will, it not be valid.
b. The nurse confiscated the cellphone from the patient’s
room and tell him it is being locked in the vault
c. staff members confiscated written letters done by
patients addressed to local news paper.
d. Patient is paid minimum wage for helpin the hospital
kitchen.
238. Which of the following is NOT covered in Patient’s
Bill Of Rights?
a. Refusal to treatment
b. Informed Consent
c. Right to Treatment
d. Civil Commitment
239. A patient has been advised by the psychiatrist
that he needs inpatient hospitalization. The patient
agrees, signs the admission forms. And agrees to
received treatment. What type of admission is this?
a. formal
b. Voluntary
c. Informal
d. Involuntary
240. Disclosure of client information beyond the
interdisciplinary team without consent of the client is
a breech of ___________.
a. Confidentiality
b. Beneficence
c. Duty
d. Veracity
Situation 19 – Nursing research is conducted to answer a question
or resolve problems on the relevance of the nursing profession
________.
241. The nurse develop the following hypothesis: Elderly woman
receive less aggressive treatment for terminally ill spine patients
that younger women. Which variable would be considered to be
dependent variable?
a. Degree of treatment received
b. age of the patient
c. Use of patient treatment
d. Type of complication being treated
242. the following are considered qualitative research
EXCEPT?
a. Sample
b. Literature review
c. Hypothesis
d. Data collection
243. Which of the following example of a PRIMARY
source un study.
a. A textbook of medical-surgical nursing
b. A doctoral dissertation that critiques all research in
area of attention deficit disorder
c. A published commentary on the finding of another
study
d. A journal article about a study that used large,
previously unpublished databases generated.
244. What is the best source to use when conducting a
level ONE 1 systematic meta-analysis of the
literature?
a. An electronic database and doctoral dissertations
b. An electronic database
c. doctoral dissertations
d. The Cochrane Statistical method
245. Which type of research allows reseachers to be
neutral observers?
a. Quantitative research
b. Ethnographic research
c. case studies
d. Qualitative research
Situation 20 – Mrs. Gomez, 63-year-old admitted for
cataract extraction, Nurse lucy is assigned to prepare the
patient for surgery.
246. Mrs. Gomez tells the nurse that she does not want to
know about surgery. What would be the best response of
the nurse.
a. “I must go over certain information with you”.
b. “You are right; do not worry yourself tonight”.
c. “You really sound quite concerned about you sugery”.
d. “Well, I could talk to your son about this instead”.
247. What should the nurse do before giving pre-operative
teaching to the patient?
a. determine Mrs. Gomez anxieties, level of understanding
and expectations.
b. Research the surgical procedure so as to give step-to-
step explanation
c. Schedule teaching to begin 2-3hours before surgery.
d. Give Mrs. Gomez general information because specifics
night be threatening
248. While doing health teaching to MRS. Gomez, the
attending nurse can BEST recognize that her patient is
learning by ____.
a. demonstrating a positive change in her behavior.
b. Constant verbal reaffirmation that she
understands
c. her ability to repeat what was discussed
d. nonverbal acknowledgement that she
understands, such as nodding.
249. The nurse prepare Mrs. Gomez for discharge.
What would be the nurse MOST important post
cataract surgery instruction to her patient?
a. Avoid the use of laxatives
b. use an eye shield at night
c. Avoid to touch the eye dressing
d. Curtail most heavy activities
250. After discharge, Mrs. Gomez attends the eye
clinic for follow – up visit. When she received the
cataract glasses, it is important that the nurse advice
her that _________.
a. magnification by the lens is only about 10 percent
b. daily eye drops are required with eyeglasses
c. her peripheral vison will be increased
d. objects will appear closer that they really are
THE END